Severe respiratory distress with use of accessory muscles
Q. A 45-year-old male is brought to the emergency room in a confused state. He was found at a road accident site. His vitals are, Temperature: 36.3C(97.5F); PR: 140/min; RR: 20/min; and BP: 80/30mm Hg. His pupils are bilaterally reactive. On examination he is in severe respiratory distress with use of accessory muscles. Trachea is deviated to the right and breath sounds are absent on the right side of chest. There is dullness to percussion on right side of chest. His heart sounds are normal without any murmurs. A chest-x ray shows linear fracture of right fourth and fifth ribs with collection of fluid in the right side of thorax with collapse of right lung. What would be the most appropriate management in this patient?
A. Do a right surgical thoracotomy.
B. Insert an intercostal tube in right side of chest.
C. Do a needle thoracotomy in right second intercostal space.
D. Do an angiography.
E. Do a CT scan of chest.
Massive hemothorax: is common in both penetrating and blunt chest injuries. Patients who sustain acute hemothorax are at risk for hemodynamic instability due to loss of intravascular volume and compromised central venous return due to increased intrathoracic pressure. Lung compression due to massive blood accumulation may also cause respiratory compromise. Sources of hemothorax are: lung, intercostal vessels, internal mammary artery, thoracicoacromial artery, lateral thoracic artery, mediastinal great vessels, heart, abdominal structures (liver, spleen) when diaphragmatic hernia.
The diagnosis is readily made from the clinical picture and X-ray evidence of fluid in the pleural space. Primary thoracentesis is carried out to confirm the diagnosis. Optimal therapy consists of the placement of a large (36 French) chest tube.